Training

The flight instructor's inadequate supervision of the flight, including his failure to maintain an approach airspeed consistent with the airplane's configuration, which resulted in an aerodynamic stall due to slow airspeed, and subsequent uncontrolled descent into trees. Factors were the icing conditions, the flight instructors failure to turn on the wing and engine anti-ice, and his lack of experience as an instructor pilot in the airplane.

An engineering investigation found no fault with the aircraft that might have caused the accident. The investigation concluded that the most probable cause was an inadvertent retraction of the landing gear whilst the aircraft was still on the ground. The confusion over individual roles would have been resolved if the examiner had given a pre-flight briefing in line with the guidance contained in the FAA Designated Examiners' Handbook, but both pilots have stated that this briefing did not take place. In any event, the FAA Handbook and FARs are unclear on who should be the commander of the flight although FAR 61.47 states the examiner is not normally to be the Pilot in Command except by prior agreement with the applicant or other person who would normally be acting as Pilot in Command. Nevertheless, it is clear that the instructor should have been briefed that he was fulfilling the safety pilot role and was responsible for "protect(ing) the overall safety of the flight to whatever extent is necessary". If the instructor had clearly understood this responsibility, he might have monitored the owner's actions more closely during the touch-and-go and might have intervened earlier. Notwithstanding the confusion, the instructor took control when he considered that the owner was not taking appropriate action to control the aircraft, although the actual moment that he took control is in dispute. Given the owner's belief that the instructor was the commander and that the instructor was in any case by far the more experienced pilot, it is not surprising that he relinquished control even though, unknowingly, he had a more complete understanding of the aircraft's predicament. The flight time from the propeller strikes to the next ground impact was only a few seconds. Once the aircraft became airborne with a significant amount of power applied and a badly damaged left propeller, the situation was well beyond any emergency for which either pilot might have trained. The options for action were very limited and would have required a full appreciation of the circumstances, plus extremely rapid analysis and reactions if those actions were to be successful.

The flight crew's failure to cycle the deice boots prior to conducting a simulated forced landing and their failure to maintain adequate airspeed during the maneuver, which resulted in an inadvertent stall and subsequent loss of control. A contributing factor was the ice accumulation on the leading edges of the airfoils.

By clear and convincing evidence, the cause of this mishap was an uncharacteristic loss of situational awareness by the entire mishap flight deck crew and the subsequent lack of an appropriate response to obstacle warnings. The Board President further found the following factors substantially contributed to the mishap: overall crew preparation, a misdirected focus on the weather, crew resource management dynamics, and crew judgment as it relates to existing directives.

Engine failure for unknown reasons.